September 15, 2011

Forget the lottery. Search out medicare/medicaid fraud

One disabled man in New Jersey did and earned $15.4 million.

In the U.S. a "qui tam" action can be brought by any individual under the False Claims Act with knowledge of past or present fraud against the federal government to bring suit on its behalf. Whistleblowers, called "relators" , the person filing under the act stands to receive 15-25% of any recovered damages. With at least $87 billion a year lost to Medicare/Medicaid fraud, there exists the potential to make a
great deal of money for enterprising individuals or groups employing all the technological tools and information at hand to ferret out fraud.

Richard West was shocked when he went for some dental work and found his Medicaid benefits had maxed out.
Pulling up his Medicaid record, he totaled the care he'd received, the bills submitted by his provider -- and found the problem.
According to The Star-Ledger, West, 63, found the company arranging his nursing care,Maxim Healthcare, was over-billing the government for hundreds of hours of service from people he'd never seen.

After calling several government hot-lines and receiving no help, he got a lawyer of his own. That phone call unraveled a fraud stretched across 40-states and resulted in a $150 million settlement -- the largest for healthcare fraud in history. Monday, Maxim agreed to return $121.5 million in state and federal claims; $8.4 million to the VA, and pay a $20 million fine.

A one-time auto mechanic, truck driver, commercial fisherman and carpenter before his disease — a genetic disorder that prevents muscles from functioning — put him in a wheelchair, West gets 16 hours of nursing and home health care a day. He said he brought his case only because no one would listen to him.

He said it was not hard to figure out what was going on. "The hard part was turning them in," he remarked. West, who lives in Tuckerton, said he tried going through a county social worker, to the state Medicaid waiver office, and then the Medicaid hot line for fraud. "No one ever did anything," he complained.

Robin Page West, his attorney (and no relation to him), said winning will be a mixed blessing. "He no longer qualifies for Medicaid," she noted with a smile.

"The three most salient characteristics of Medicare and Medicaid fraud are: It’s brazen, it’s ubiquitous, and it’s other people’s money, so nobody cares," writes Michael Cannon in Entitlement Bandits.

Judging by official estimates, Medicare and Medicaid lose at least $87 billion per year to fraudulent and otherwise improper payments, and about 10.5 percent of Medicare spending and 8.4 percent of Medicaid spending was improper in 2009. Fraud experts say the official numbers are too low. “Loss rates due to fraud and abuse could be 10 percent, or 20 percent, or even 30 percent in some segments,” explained Malcolm Sparrow, a mathematician, Harvard professor, and former police inspector, in congressional testimony.